· Identify a policy that is not usually intended to be a health policy but that you think may have important health implications.
One such policy might be the provision of universal childcare, which would offer free daycare and preschool services (and ideally afterschool services as well), particularly to poor families. I think universal childcare could have multiple health impacts for children and parents. For example, one outcome might be a reduction in childhood obesity. The Ludwig et al. (2011) paper made me realize that broad and general changes to environment may have measurable impacts on nutritional and metabolic health. I can imagine that if we had well-run, regulated day care programs that made a commitment to serve healthy food and provide safe opportunities for physical activity, a 5-day per week intervention like preschool could improve children’s health. Likewise, there may also be spillover effects on to parents’ health. With working parents less burdened by childcare (or the cost of childcare), they may have increased work productivity which could leave to better income and opportunities for advancement. Furthermore, healthy food provided at daycare/preschool relieves some of the burden that falls on parents. It is not uncommon for struggling families to depend on unhealthy foods (so called “cheap calories”) for snacks and meals; perhaps some of these monetary and time savings would make it easier to obtain and prepare healthy meals.
· Describe why an evaluation of that policy is informative (e.g., determining effects of the policy, or primarily a test of hypothesized mediators).
For such a large and potentially expensive undertaking, governments need to know that they investment is a good one. Evaluating the proposed policy, including all of its downstream effects, will be necessary to prove whether the policy should be funded. Once effects of (or associations with) this policy are determined, studying the mediators of those effects could uncover new insights about the social determinants of health.
· Specify the outcomes and populations you think most affected or least affected by the policy.
I hypothesize that poor children and families in food deserts will be most affected by this policy. These families might be urban or rural, but I would expect the largest effects in high-poverty areas where childcare services are either low quality and unaffordable or nonexistent. The outcome I would expect to see a difference in the soonest would be childhood BMI, particularly at the time of transition from preschool to grade school.
· Propose a study design to evaluate the policy.
If this program were piloted in some high poverty neighborhoods, children who had access to free daycare/preschool/afterschool could be followed as a prospective cohort. If possible, a sort of cluster randomized trial could also be done with “placebo groups” of same-aged children in comparable SES neighborhoods without access to the program.
· Describe biggest challenge to implementing and drawing inferences about the impact of the policy on health.
The biggest challenge to implementing this type of ambitious social program will be cost (as always). It is also non-trivial to find qualified enough childcare workers to staff the proposed programs. Studying the program, particularly as proposed above, will be very difficult because the proposed outcomes may not be apparent for 2-3 years (children need to be enrolled long enough to derive health and fitness benefits).